Tuberculosis in Dentistry: Oral Manifestations, Diagnosis, and PrecautionTuberculosis in Dentistry: Oral Manifestations, Diagnosis, and PrecautionTuberculosis in Dentistry: Oral Manifestations, Diagnosis, and Precaution

1. The Temporomandibular joint disorders

2.  The TMJ is a synovial bilateral joint that permits the mandible
to move as a unit with 2 functional patterns ( hinge and
translatory (gliding) movements).
Normal anatomy
The basic components of the TMJ include
:
•
The mandibular component, i.e. the head of the condyle
•
The disc
•
The temporal component, i.e. the glenoid fossa and articular
eminence
•
The capsule surrounding the joint
.
The normal movements include
:
•
Hinge or rotation of the condyle within the fossa
.
•
Translation movement of the condyle down the articular
eminence. The disc being attached to the condyle also moves
forwards
.
These two movements together result in the downward and forward
movement of the condyles when patients open their mouths
.

3. Diagrams showing the rotary and
translatory movements of the
condyle during normal mouth
opening
.

5. Mouth closed Mouth open

6. A B C
D
Sagittal Reformat CBCT Image. A to C,
Closed position. A, Lateral image slice.B,
Central image slice. C, Medial image slice of the
same joint. Notice that the condyle appears
retruded in the lateral slice, centered in the
central slice, and anteriorly positioned in the
medial slice. D, Open view showing the degree
of condyle translation during mandibular
opening
.

7. Disorders of the TMJ
• TMJ myofascial pain dysfunction syndrome
(MPDS)
• Internal derangements
• Osteoarthritis (osteoarthrosis)
• Rheumatoid arthritis
• Juvenile rheumatoid arthritis (Still's disease)
• Ankylosis
• Tumours
• Fractures and trauma
• Developmental abnormalities
1
-
Condylar Hyperplasia
2
-
Condylar Hypoplasia
3
-
Coronoid Hyperplasia
4
-
Bifid Condyle
5
-
Condylar Aplasia

8. TMJ myofascial pain dysfunction syndrome (MPDS):
This is the most common clinical diagnosis applied to patients with:
 Pain in the muscles of mastication, often worst in the early morning
and evening , with occasional clicking and stiffness.
The etiology : anxiety or depression, malocclusion, or muscle
spasm.
Main radiographic features
:
•
Normal condylar head shape and articular surface
.
•
Normal glenoid fossa shape
.
•
Possible increase or reduction in the overall size of the joint space ( an
increase in the size of the joint space is only indicative of
inflammation
.)
•
Possible displacement of the condylar head anteriorly or posteriorly in
the glenoid fossa when the mouth is closed and the teeth are in
occlusion
.
•
Reduction in the range of condylar movement
.

9. Internal Derangements
:
 Abnormality in the position and sometimes the morphology of the
articular disc that may interfere with normal function.
 Unknown cause or due to parafunction, direct trauma, and
forced opening beyond the normal range
.
 The disc most often is displaced in an anterior direction, but it may
be displaced anteromedially, medially, or anterolaterally. Lateral
and posterior displacements are rare.
 The disc may resume a normal position with respect to the condyle
(called reduction of the disc) during mandibular opening; when the
disc remains displaced throughout the entire range of mandibular
movement, the term non reduction is used.
 A longstanding displaced disc may become deformed, losing its
normal biconcave shape, and it may become thickened and fibrotic.
 Complications are degenerative joint disease and perforation
through the disc or (more commonly) the posterior attachment.
-
Internal derangements can be diagnosed by MRI
.

10. Position and movement of the disc during jaw opening
.
Normal position (A), mildly displaced anteriorly (with reduction , B ), and
severely displaced anteriorly (without reduction, C )
.

11. Position and movement of the
articular disc during jaw opening:
Top, Normal position
.
Middle, Partially displaced
anteriorly (with reduction)
.
Bottom, Severely displaced
anteriorly (without reduction)
.

12. Symptoms include:
 Clicking which may be painful.
 Pain from the joint and/or musculature.
 Trismus and hesitation of movement and locking usually
with failure of opening.
 Conventional radiography may have revealed an alteration
in the position of the head of the condyle, implying an
abnormality in disc position.
MRI is the investigation of choice to show:
• Disc position — it may dislocate anteriorly or
anteromedially
• Disc movement relative to the condyle during opening and
closing.

13. Important clinical features
:
 Joint noises, such as popping or clicking, are a common sign
of disc displacement but usually are not painful.
 Crepitus,a crunching or grinding sound, is suggestive of
osseous degeneration associated with a long-term, non-
reducing disc.
 Symptoms associated with a displaced disc include pain in
the preauricular region, headaches, and closed or open
locking of the joint.
 A decreased range of motion may be present, and
when the displacement is unilateral, this may manifest as
deviation of the mandible to the affected side on opening
.

14. Osteoarthritis:
 This degenerative arthrosis increases with age.
 Causes pain in the stress bearing joints, such as the hips and spine.
Symptoms:include painful crepitus and trismus which are usually persistent.
Main radiographic features
• Osteophyte (lipping) formation on the anterior aspect of the articular
surface of the condylar head. Extensive osteophyte formation is referred to
as beaking. Flattening of the head of the condyle on the anterosuperior
margin .
• Subchondral sclerosis of the condylar head which becomes dense and more
radiopaque .
• A normal outline to the glenoid fossa though it may also become sclerotic.

15. Beaking
flattening
Rheumatoid arthritis
 Is a heterogeneous group of systemic disorders
that manifests mainly as synovial membrane
inflammation in several joints.
 Main radiographic features:
•
Flattening of the head of the condyle
.
•
Erosion and destruction of the articular surface of
the head of the condyle which may be extensive
causing the outline to become irregular
.
•
Occasional osteophyte formation on the condyle
.
•
Hollowing of the glenoid fossa
.
•
Reduction in the range of movement
.
•
Features are usually bilateral and fairly
symmetrical
.

16. Juvenile rheumatoid arthritis (Still's disease)
Is a chronic rheumatologic inflammatory disease that manifests
before age 16 years (mean age, 5 years).
 Manifests as condylar hypoplasia and characteristic
morphologic abnormalities.
 It affects children and adolescents during the growth of
mandible.
 More common in females.
 Incidental finding in a panoramic projection.
Radiographic appearance:
 Condylar head develops a characteristic “toadstool” appearance.
 Condylar neck is shortened or even absent in some cases
Treatment: orthognathic surgery
orthodontic therapy

17. The condylar heads have a toadstool appearance & are posteriorly
inclined. The condylar necks are absent
.

18. Ankylosis
:
True ankylosis: fusion of the bony elements of the joint
.
Causes
:
•
Trauma, particularly condylar head fractures and birth injury,
and bleeding into the joint
.
•
Infection
•
Severe juvenile rheumatoid arthritis
.
Main radiographic features
•
Little or no evidence of a joint space
.
•
Bony fusion between the head of the condyle and the glenoid
fossa with total loss of the normal anatomical outlines
.
•
Associated evidence of condylar neck hypoplasia and
mandibular underdevelopment on the affected side producing
asymmetry
.

20. Tumours:
• Benign or malignant tumors affect the head of the condyle.
• either intrinsic or extrinsic.
• Intrinsic develops in condyle, temporal bone or coronoid
process.
• Extrinsic tumor may affect the morphology, structure and
function of the joint without invading the joint itself.
Benign Tumors:
Osteoma, osteochondroma, Langerhans histocytosis and
osteoblastomas,Chondroblastomas, fibromyxomas, benign giant
cell lesions and anneurysmal bone cysts.
Benign tumors and cysts of the mandible may involve the entire
ramus and condyle
Grow slowly, TMJ swelling ,Pain and decrease in range of
motion.
While tumors of coronoid process are painless but may complain
of progressive limitation of motion.

21. * Radiographic Features:
Condylar enlargement with irregular outline.
Osteoma and osteochondroma appear as abnormal, pedunculated
mass attached to the condyle.
• Treatment: Surgical excision of tumor and occasionally
excision of condylar head or coronoid process.
• Malignant Tumors:(black arrows)
• A- Primary (rare): - Intrinsic
• - Extrinsic
• Intrinsic: Chondrosarcoma
• Osteogenic sarcoma
• Synovial sarcoma
• Fibrosarcoma
• Extrinsic: Direct extension of adjacent parotid salivary gland
malignancies.

22. B. Metastatic (more common)
May be asymptomatic or patients may have symptoms of TMJ
dysfunction (pain, limited mandibular opening, mandibular
deviation and swelling)
*
Radiographic Features
:
Variant degree of bone destruction with ill defined, irregular
margins
CT modality of choice
MRI useful for displaying extent of involvement into surrounding
tissues
.
*
Treatment
:
Surgical removal of tumor
.
May include radiotherapy and chemotherapy
.

23. Cropped OPG shows
destruction of the right
condyle from a metastatic
lung carcinoma with a
secondary fracture (arrow)
.

24. Fractures and trauma:
• Fractures of the condylar necks are common after a blow to
the chin . With this type of injury the condylar neck does not
fracture but the head of the condyle either fractures, a so-
called intra-capsular fracture ,or is forced upwards, through
the glenoid fossa into the middle cranial fossa .
• CT will demonstrate the extent of any injury. Trauma can
also result in unilateral or bilateral dislocation .

25. A 14-year-old girl suffered bilateral condylar fractures with an
additional symphysis fracture of the mandible and multiple dental
injuries due to fainting and ground-level fall. A dental panoramic
radiograph image shows a sagittal corpus fracture (wide arrow) and
bilateral condyle fractures (small arrows) of the mandible, which
were more detectable with additional imaging
.

26. OPG: showing bilateral dislocation of the
condyles (open arrows) out of the glenoid fossae (white arrows)
.

27. OPG image showing bilateral dislocation of the condyles
.

28. Developmental abnormalities
• Developmental abnormalities are the result of disturbances in
the normal growth and development of the TMJ, which may
affects the form or size of the joint components, most
commonly the mandibular condyle.
• Because the condylar articular cartilage is considered a
growth center for the mandible, disturbances involving this
cartilage can result in altered growth of the mandibular
condyle, ramus, body, and alveolar process on the affected
side.

29. 1
-
Condylar Hyperplasia
:
-
Enlargement and deformity of the condylar head
.
-
Secondary effect on the mandibular fossa as it remodels to
accommodate the abnormal condyle
.
Etiology
:
• Trauma, infection, hereditary and hypervascularity.
• More common in females.
• The condition usually is unilateral.
• Self limiting, arrest with the termination of skeletal
growth.
• Progresses slowly or rapidly.
• Mandibular asymmetry, with an increase in the vertical
dimension of the ramus, mandibular body, or alveolar process
of the affected side.
* Which results in posterior open bite on the affected side or a
crossbite on the contralateral side with problems in mastication or
speech
• Chin deviated to the unaffected side.

32. Radiographic Features
:
 May appear normal but symmetrically enlarged or it may be
altered in shape (e.g., conical, spherical, elongated, lobulated)
or irregular in outline
.
 May be more radiopaque due to additional bone present.
 Condylar head & neck may be elongated with a compensating
forward bend, forming an inverted L
.
 Glenoid fossa may also be enlarged.
 Ramus and mandibular body on the affected side also may be
enlarged, resulting in a characteristic depression of the inferior
mandibular border, increased vertical dimension of ramus and
may be thicker in the anteroposterior dimension.
Treatment
:
Orthodontics combined with orthognathic surgery
.

33. 2- Condylar Hypoplasia
 Failure of the condyle to attain normal size .
 Congenital and developmental abnormalities or acquired(trauma,
infection, and therapeutic radiation exposure to the condyle during
growth are acquired causes) that affect condylar growth.
 Small condyle with normal morphology.
 Underdeveloped ramus and occasionally mandibular body.
 Unilateral or bilateral.
 Deviated chin to affected side, mandible deviates to affected side on
opening.
Radiographic Features:
 The condylar neck and coronoid process usually are very slender and
are shortened or elongated in some cases.
 The ramus and mandibular body on the affected side may also be
small, resulting in a mandibular asymmetry and occasional dental
crowding, depending on the severity of mandibular
underdevelopment.
Treatment: Orthognathic surgery / Bone grafts.
Orthodontic therapy maybe required.

34. Facial asymmetry and the chin to the left of the midline
.
The mastoid process is visible on the left
.
The occlusal plane is higher on the left, with posterior crossbite
.

36. Panoramic image reveals hypoplasia of the right condyle with the
associated short vertical height of the right mandibular ramus and
body
.

37. CBCT images of unilateral
condylar hypoplasia. Reconstructed
sagittal (A and B) and coronal
(
C and D
)
images
.
(
A and C
)
The right condyle is
hypoplastic, and with secondary
remodeling. The articular surfaces of
the condyle and anterior aspect of the
glenoid fossa are flattened, and
the superior joint space is thinner
compared with the left
.
(
B and D
)
Left side of the same
patient showing normal condyle
.

38. 3
-
Coronoid Hyperplasia
:
Elongation or enlargemen of the coronoid process
.
-
Developmental > bilateral
.
-
Acquired > uni or bilateral
.
-
Inability to open mouth
.
-
Painless
.
Radiographic features:
- TMJs usually appear normal
- Unilateral cases should be differentiated from a tumor of the
coronoid process (osteochondroma or osteoma),unlike coronoid
hyperplasia, tumors have an irregular shape.
- Treatment: surgical removal or the coronoid process and
postoperative physiotherapy

39. (
A
)
Panoramic image reveals bilateral coronoid
hyperplasia (arrows) in a patient complaining of limited
opening
.

40. (
B and C
)
Reconstructed corrected sagittal CBCT images of a
patient with bilateral coronoid hyperplasia. Note the
pronounced elongation of the coronoid processes but with
maintenance of a normal shape
.

41. Anterior hook formation ﬇. Upon
opening, this hook engages an
exostosis on the zygoma. The
mandibular notch is shallow and
the condyle, notch, and coronoid
process resemble a "check mark
.

42. 4- Bifid Condyle:
 Vertical depression, notch, or deep cleft in the center of the
condylar head,which is best seen in the corrected sagittal or
coronal plane, results of a “double-headed” condyle.
 Rare, often unilateral
 Incidental finding
 Some patients may have sings of TMDs (noises + pain)
Radiographic Features:
Depression on the superior condylar surface giving a heart
shape.
•
Etiology
○
Congenital – Genetic factors, endocrine disorders
○
Developmental – Obstructed blood supply during development,
persistence of fibrovascular septa in developing condyle
○
Acquired – Teratogenic embryopathy, nutritional deficiency,
infection, irradiation, trauma
.

44. Bifid condyle. Reconstructed corrected sagittal (A) and coronal
(B) images show a central depression in the superior surface of the
mandibular condyle creating a heartshaped outline. The osseous
structures in this joint are normal
.

45. 5
.
Condylar Aplasia
:
Anomaly of unknown origin that effects TMJ development, unilateral
.
○
Missing condyle and associated lack of glenoid fossa development
.
○
Associated with ipsilateral facial malformations (ear, muscles, mouth)
.
•
CBCT shows
:
○
Condyle absent
.
○
Lack of glenoid fossa and articular eminence development
.
○
Small unilateral ramus – Teeth developing in small ramus
.
○
Small body of mandible
.
○
Defect rarely extends to bicuspid region
.
○
Hypoplasia of mastoid on affected side
.
○
Coronoid may be present or reduced in
size
.